Which came first, the chicken or the egg?

That question came to mind when I read an article in today’s Guardian, Growing childbirth terror disorder ‘fuelled by social media’.

Catriona Jones, a lecturer in midwifery at the University of Hull, who has studied tocophobia, believes social media is partly to blame for the phenomenon.

Speaking at the British science festival, taking place at the university, she said: “You just have to Google childbirth and you’re met with a tsunami of horror stories.

“If you go onto any of the Mumsnet forums, there are women telling their stories of childbirth – oh, it was terrible, it was a bloodbath, this and that happened. I think that can be quite frightening for women to engage with and read about.

Jones has adopted the position that the proverbial chicken came first. Fear of childbirth is implied to be a cultural construct that does not reflect the reality of nature. It arrives fully formed in response to socialization through frightening birth stories.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Midwives are employing the classic misogynist tactic of muzzling women who seek community and validation in sharing their experiences.[/pullquote]

Medieval philosophers also thought the chicken came first:

By the end of the 16th century, the well-known question seemed to have been regarded as settled in the Christian world, based on the origin story of the Bible. In describing the creation of animals, it allows for a first chicken that did not come from an egg.

They “knew” the chicken came first because their Bible told them so. Similarly, Ms. Jones “knows” that the chicken of fear of childbirth came first because her bible told her so. It is an article of faith among natural childbirth advocates that pain in labor comes from fear and fear comes from socialization.

But science tells us that it was the egg that came first:

…[A]n animal nearly identical to the modern chicken (i.e., a proto-chicken) laid a fertilized egg that had DNA identical to the modern chicken (due to mutations in the mother’s ovum, the father’s sperm, or the fertilised zygote). Put more simply by Neil deGrasse Tyson: “Which came first: the chicken or the egg? The egg — laid by a bird that was not a chicken.”

Science also tells that it the pain and the death toll of childbirth that led to fear, not socialization. The pain of childbirth is thought to have had the evolutionary purpose of promoting the purely human behavior of assistance in childbirth. Human childbirth is inherently dangerous and assistance can mitigate the risk by manipulating the baby out of a difficult position or by massaging the uterus to prevent hemorrhage after birth. A woman in pain sought out help; a woman who sought out help was more likely to survive; ultimately painful labor spread through the population because it was evolutionarily advantageous.

The death toll of childbirth speaks for itself. In every time, place and culture childbirth has always been a leading cause of death of young women. In countries where pre-technological conditions remain, the lifetime risk of maternal mortality has been as high as 1:10 as recently as 1990.

Even if science didn’t give us the answer, history tells us that the idea that labor pain is a construct of modern Western culture is nonsensical. The people who wrote the Bible were so impressed by the extreme agony of labor that they explained it as nothing less than a grievous punishment from God.

May midwives insist that the pain of labor is a cultural construct for a very simple reason: self-dealing. They have lost the care of a large proportion of women to obstetricians because OBs can abolish the pain of childbirth and midwives cannot. Living in our culture, where people are socialized to imagine that anything they like is natural and anything they dislike is a cultural construct, they have resorted to the foolish claim that painful childbirth is result of socialization, transmitted in this case by social media.

Midwives thus make stupifyingly ignorant claims like this:

Julie Jomeen, a professor of midwifery and the dean of the faculty of health sciences at the University of Hull, said: “Tocophobia is a modern-day phenomenon. Some of these women really think they are going to die.

“Two hundred years ago people accepted that they might die from childbirth. Today we expect childbirth to be safe.”

What? Does Jomeen think that women didn’t fear childbirth prior to the 20th Century? We have copious written evidence from women themselves that they viewed childbirth with unalloyed horror, dreaded the pain, feared the deaths of their children, and perhaps most anguishing of all, were terrified that they would leave their older childbirth motherless.

Is Jomeen trying to suggest that prior to the 20th Century women accepted the possibility of their own deaths with equanimity? Every bit of historical evidence we have shows that all people (men and women) have feared their own deaths throughout recorded history. Yes, they were surrounded by premature death; yes, their religious practice was designed to prepare them for death; but they still resisted death any and every way they knew how.

What’s going on here? The irony is that the midwives accuse women of being socialized to fear labor are oblivious to the fact that THEY are the ones who are blinded by a cultural construct. THEY are socialized to believe, despite massive evidence to the contrary, that labor is enjoyable, empowering and worthy of embrace.

As Suzanne Moore, also of The Guardian notes:

Women fear childbirth because pushing out another human being through a small opening in your body is to be split asunder…

The fear is rational. When women tell each other birth horror stories nowadays, this is not an exercise in fiction. They are telling the truth.

But there is another larger and more tragic irony here. Midwives who claim to be promoting a feminist ideal of birth are employing the classic misogynist tactic of muzzling women who seek community and validation in sharing their experiences.

If you feel mentally and physically traumatised, please do keep talking. You are not spreading fear. Because women sharing their truths, however bloody messy these are, is actually how we change things.

It is only through sharing the agony of postpartum depression that women have forced medical providers to take action. It is only through sharing maternal deaths (including sharing by journalists) that women have forced providers to take action. Similarly, it is only through sharing stories (especially sharing by the Fed Is Best Foundation) of babies harmed by aggressive breastfeeding promotion that women are gradually forcing medical providers to acknowledge the dangers and take action against unscientific programs like the Baby Friendly Hospital Initiative.

Social media has serious problems, but those problems concern empirical facts not personal experiences. Indeed, social media can serve as repository of and witness to raw human suffering and can elicit the best in human nature through campaigns, emotional and financial, to support those who are suffering. Moreover, social media is remarkably democratic, allowing anyone to communicate with the world, not merely those who satisfy a publishers’ prejudices.

Disparaging women who share their stories of childbirth agony, injuries and trauma on social media is a particularly chilling way to control discourse. Not only does it blame the victim but it also seeks to disempower women from preventing victimization. If you don’t know about the dangers of childbirth, you can’t protect yourself from them. If you don’t know about the agony of childbirth, you can’t mentally prepare yourself for it. And if you don’t know about the suffering that childbirth causes many women, you may needlessly, regrettably end up blaming yourself when it happens to you.

Bravo to Milli Hill for being willing (at least temporarily) to engage outside her comfort zone of UK midwives and natural childbirth advocates.

She unblocked a number of midwifery critics in an effort to convince them of the rightness of her convictions. But like an anti-vaxxer, Milli appears to be utterly flummoxed that we aren’t persuaded by the “facts” as she understands them. Similar to the typical anti-vaxxer, she doesn’t understand that she has been living in an alternative world of internal legitimacy.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]UK midwives never having to face dissent, respond to real scientific evidence or acknowledge that most of what they claim is factually false.[/pullquote]

That phrase was coined by the author of The Legitimacy of Vaccine Critics: What Is Left after the Autism Hypothesis? by Anna Kirkland.

[They] have built an alternative world of internal legitimacy that mimics all the features of the mainstream research world — the journals, the conferences, the publications, the letters after the names — and some leaders have gained access to policy-making positions…

Consider:

Journals: There are a plethora of midwifery and natural childbirth journals. For example, Birth: Issues in Perinatal Care, published on behalf of Lamaze International, is technically a peer review journal. It is made up in large part of papers written by editorial board, which includes such luminaries of the natural childbirth world as Eugene Declercq, Marc J.N.C. Keirse, Michael Klein, and Marian F. MacDorman. Birth is where you send your paper if you can’t get it published in a real medical journal, and it carries little influence in the world of obstetrics. Every country has at least one peer reviewed midwifery journal and many non peer reviewed “journals” like the Journal of Perinatal Education, another Lamaze production, and Midwifery Today.

Conferences: Midwives and natural childbirth advocates love conferences like the Normal Birth Conference, the Trust Birth Conference and conferences of midwifery trade organizations. Unlike traditional scientific conferences where all viewpoints are heard on vigorous disagreements aired, midwifery conferences are heavily censored to remove dissenting views with the express purpose of creating an echo chamber for non-scientific claims. Sure, some doctors are allowed, like Michel Odent, Marsden Wagner and now Neel Shah, but only if they’ve been vetted for ideological purity beforehand.

Moreover, you won’t find midwifery academics and theorists on the speakers’ list at obstetric conferences, first because they aren’t respected within the greater obstetric and scientific communities, and second because they wouldn’t dare appear at a place where they would be laughed off the stage for their fanciful claims.

Libertarian individualist account of health: Midwives and natural childbirth advocates like to invoke all sorts of made up rights, like the “birth as a human right,” and the “right” to be attended by the provider of one’s choice in the place of one’s choice. They decry government regulation, yet, ironically, spend a great deal of time lobbying for government involvement in promoting and paying for favored birth choices and providers.

As Kirkland explains about anti-vaxxers:

[They] share an internally bounded world in which both individuals and ideas enjoy legitimacy, but undercut the groups’ external legitimacy …(emphasis in original)

But preserving internal legitimacy is considered far more important, hence Sheena Byrom and her UK midwifery clique block everyone who might possibly disagree with them. They insist that they are blocking trolls but the definition of “troll” belies that claim.

According to Wikipedia:

…[A] troll is a person who starts quarrels or upsets people on the Internet to distract and sow discord by posting inflammatory and digressive, extraneous, or off-topic messages … with the intent of provoking readers into displaying emotional responses and normalizing tangential discussion.

But I and like minded midwifery critics aren’t trying to distract, provoke midwives into displaying emotional responses or normalize tangential discussions. We are trying to engage on the issues, analyze scientific evidence, and subject claims to thorough analysis.

Kirkland asks a question about vaccine rejectionists that can also be asked about UK midwives:

Under what conditions could we imagine leaders reporting back at a later conference that the right study had finally been done and proved them wrong?

The answer, of course, is never.

UK midwives occupy an alternate world of internal legitimacy, which means never having to face dissent, never having to respond to real scientific evidence, and never having to acknowledge that most of what they claim is factually false.

It remains to be seen what Milli Hill will do about her cognitive dissonance. Will she be motivated to read the scientific literature, analyze it and seek out the papers of those who disagree with midwifery claims? Or will she take the easy route and subside back into the comforting community of like-minded believers inhabiting an alternate world of internal legitimacy?

Imagine that we set up our system of cardiology care like this:

Our bedrock assumption is that hearts are to be trusted.
We reduce screening measures since they only lead to more tests.
We deny that risks factors have any relevance.
We put initial cardiac care into the hands of nurses who have limited training in treating heart attacks.
We wait until people develop symptoms like chest pain and shortness of breath before we investigate.
We avoid high tech measures as long as possible.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Everyone who cares for pregnant women must have a high index of suspicion for complications and must treat early signs without delay.[/pullquote]

Would anyone be shocked if cardiac mortality rose as a result? I doubt it since we know that the key to cardiac care is prevention including routine blood pressure monitoring, routine treatment of asymptomatic high blood pressure, additional testing for people with risk factors and high tech investigation at the first sign of potential cardiac problems.

You don’t need to imagine how we’ve set up our maternity care system. We’ve eroded the technocratic model of obstetric care under pressure from the “holistic” midwifery model of care.

The bedrock assumption of midwives, doulas and natural childbirth advocates is that birth is to be trusted.
They deplore screening tests.
They minimize risk factors.
They insist that less professional training leads to better maternity care.
They wait until women develop life threatening symptoms before acting.
They avoid fetal monitoring and demonize C-sections.
They worry about the experience of birth because they assume the safety of birth is guaranteed.
They’ve created an adversarial relationship between women and their obstetricians that has led to decreasing vigilance.

Now everyone is shocked, shocked that maternal mortality has risen. We really have no excuse for our shock. We’ve allowed ourselves to forget that obstetric care ought to be preventive care, constantly assessing for risk factors and problems and aggressively treating early signs of potential complications before they become full blown disasters.

I have been writing about this issue for more than a decade and constantly emphasized four principles of preventing maternal mortality.

1. We cannot forget that pregnancy is inherently dangerous.
2. Certain groups of women are at high risk for complications
3. We must have a high index of suspicion for early signs of complications
4. We must treat those early signs aggressively

None of this is new information but we are in the midst of discovering it all over again and California is leading the way.

California’s maternal death rate fell from 13.1 deaths per 100,000 live births in 2005–09 to 7 per 100,000 in 2011–13, according to a new Health Affairs study…

They looked at why women are dying.

Two key lessons in reversing maternal mortality, [author] Main said, are denial and delay. “People want to deny that she’s as sick as she is. ‘It’s going to get better, the bleeding will stop, blood pressure will come down,'” Main said. “That invariably leads to delay in treatment.”

In other words, everyone who cares for pregnant women must have a high index of suspicion for complications and must treat early signs aggressively.

For example:

…[I]mplementing large-scale interventions by integrating providers with public health services, begins with a bundle, a quality improvement toolkit defining best practices and the creation of learning collaboratives. The largest of CMQCC’s learning collaboratives, which includes 99 hospitals that collectively report more than 250,000 annual births, reduced severe maternal morbidity among women with hemorrhage by 20% using an obstetric hemorrhage toolkit.

If we change the way we view and treat pregnant women, we can save their lives.

According to Becker’s Hospital Review:

1. Hospitals must implement and sustain a standardized approach to managing known obstetric complications and emergencies involved in pregnancy and childbirth.

2. Providers must recognize and modify care for pregnant women presenting with chronic conditions that contribute to pregnancy-related complications, including hypertension, diabetes and obesity.

3. Healthcare leaders and clinicians should have access to comprehensive clinical data on maternal health outcomes. Developing a maternal mortality review board lets providers gather data on known causes of maternal death and harm.

4. Patients, clinicians, nurses and the healthcare agencies that support them should participate in regular educational training sessions on preventing maternal harm and death, including reliable strategies and processes to mitigate unintended outcomes.

In other words, everyone who cares for pregnant women must have a high index of suspicion for complications and must treat early signs aggressively.

Why?

Because pregnancy is inherently DANGEROUS. When we forget that or choose to ignore it, women die.

But when we keep that reality front and center, train for deadly complications, drill for deadly complications, have a low index of suspicion for deadly complications and react aggressively to even the earliest signs of potentially deadly complications we can save women’s lives.

I’ve repeatedly noted that the evidence for the purported benefits of breastfeeding for babies is weak, conflicting and riddled with confounders. The actual benefits of breastfeeding are tiny, limited to 8% fewer colds and 8% fewer episodes of diarrheal illness across the entire population of infants in their first year.

The evidence for purported maternal benefits is even worse.

You’d never know it from the way that lactivists tout maternal benefits of breastfeeding. According to a recent article in Health, breastfeeding purportedly leads to these benefits for mothers:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Considering the disabling limitations of the data, there is NO basis for ANY claims of maternal benefit from breastfeeding.[/pullquote]

• Easier weight loss after birth
• Lower risk of breast cancer
• Lower risk of ovarian cancer
• Lower risk of endometrial cancer
• Lower risk of type II diabetes
• Lower risk of heart disease

But that’s not what the scientific evidence shows.

Consider this new review of the impact of breastfeeding on maternal health conducted by Alison Stuebe, MD and colleagues on behalf of the Agency for Healthcare Research and Quality (AHRQ).

I created this table to summarize their findings on a long list of diseases:

With the exception of ovarian cancer, there is insufficient evidence or only low quality evidence to support an association between breastfeeding and these diseases. And an association does not necessarily mean causation. For example, we know that the risk of ovarian cancer is related to the number of ovulatory cycles experienced by a woman. Breastfeeding can decrease lifetime ovulatory cycles and therefore may lead to a lower risk of ovarian cancer. But use of the birth control pill ALSO decreases lifetime ovulatory cycles and can provide the same benefit.

The key point is this: there is NO high quality evidence that even associates breastfeeding with the lower risk of these diseases, let alone evidence that breastfeeding causes a reduced incidence of these diseases.

But that doesn’t stop Stuebe and the other authors from making claims that are not supported by their own evidence:

Our conclusions related to the maternal benefits of breastfeeding suggest that breastfeeding is associated with lower rates of breast cancer, ovarian cancer, hypertension, and type 2 diabetes. The potential to improve maternal health could be highlighted as a rationale for improving rates of breastfeeding by health care and public health practitioners. For cardiometabolic outcomes, it has been hypothesized that lactation “resets” maternal metabolism after pregnancy, thereby reducing cardiovascular disease risk.

Wait, what? They JUST SHOWED that the evidence doesn’t support that claim and yet they are making it anyway?

This despite the fact that they acknowledge:

We concluded that low SOE supports the association between breastfeeding and reduced hypertension; however, primarily because of heterogeneity in outcome measures and study limitations, we concluded that evidence was insufficient to reach a conclusion about cardiovascular disease.

This is a perfect example of the way in which lactation professionals ignore the evidence in order to claim benefits for breastfeeding that don’t exist.

The authors admit that any claim of maternal benefits for breastfeeding is undermined by their inability to correct for confounding variables.

Several other factors may be at work. First, women in very high income countries who choose to and successfully breastfeed are typically better educated, wealthier, and more likely to engage in other beneficial health behaviors. Moreover, it is plausible that, rather than breastfeeding preventing poor maternal health, poor maternal health may prevent breastfeeding…

In their conclusion, the authors state:

The identified associations between breastfeeding and improved maternal health outcomes are supported by evidence from observational studies, which cannot determine cause and effect relationships.

Not really. The truth is that there is only insufficient and low quality evidence to support an association between maternal benefits and breastfeeding, with the exception of ovarian cancer. When corrected for confounding variables these associations may disappear entirely. In any case, an association is NOT causation. In light of these disabling limitations, there is NO basis for asserting ANY maternal benefit from breastfeeding.

Breast is NOT best.

Sure, all else being equal, fully fed with breastmilk by a well off, mentally healthy mother with access to high quality healthcare and high quality childcare who has freely chosen to breastfeed and has sufficient breastmilk has tiny benefits compared to formula feeding; but all else is rarely equal. Indeed, the scientific research shows that if the many factors in the previous statement are listed in order of importance to infant wellbeing from most important to least important, we get a list that looks like this:

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Women who have expended great effort to breastfeed need to believe that the benefits are large and are hypersensitive to any suggestion that they are not.[/pullquote]

1. Fully fed
2. Access to high quality healthcare
3. Mentally healthy mother who has freely chosen to breastfeed
4. Breastmilk

So if we REALLY cared about infant health, instead of merely pretending that we do, we’d work to ensure that every baby is fully fed, that every baby has high quality healthcare, that we do everything in our power to prevent and treat postpartum depression and only then promote breastfeding. Instead we do the opposite.

Why do we ignore the scientific evidence that the benefits of breastfeeding are tiny? Why do we ignore the growing body of scientific evidence that aggressive promotion of breastfeeding is leading to tens of thousands of neonatal hospital readmissions each year at a cost of hundreds of millions of dollars? Why do we ignore the minor epidemics of infant dehydration, severe jaundice, babies falling from and smothering in their mothers’ hospital beds leading to permanent brain injuries and even deaths? Why do we ignore the harms of aggressive breastfeeding promotion to mothers’ mental health?

The reason: effort justification.

According to Wikipedia:

Effort justification is a person’s tendency to attribute a value to an outcome, which they had to put effort into achieving, greater than the objective value of the outcome.

It’s an attempt to reduce cognitive dissonance:

[T]here is a dissonance between the amount of effort exerted into achieving a goal or completing a task (high effort equalling high “cost”) and the subjective reward for that effort (lower than was expected for such an effort). By adjusting and increasing one’s attitude or subjective value of the goal, this dissonance is resolved.

Simply put, women who have expended great effort to breastfeed — who have endured the screams of a starving baby, cracked and bleeding nipples, multiple episodes of mastitis, sleep deprivation and (in some cases) serious depression — need to believe that the benefits are large and are hypersensitive to any suggestion that they are not. That’s why the Fed Is Best Foundation is excoriated in the loudest possible terms with an endless repetition of lies.

For lactivists, the Fed Is Best Foundation is cognitive dissonance writ large. It’s very name is anathema because it suggests that breast is NOT best for every baby and it only gets worse from there. In order to protect future babies from being harmed by aggressive breastfeeding efforts, the Fed Is Best Foundation reports on existing babies who have been harmed, injured and even died from complications of breastfeeding. How dare they?

In order to protect babies, the Fed Is Best Foundation exposes the lies propounded by lactivists. Such lies include:

• The claim that insufficient breastmilk is rare (it’s common, affecting up to 15% of first time mothers)
• The lie that formula supplementation is harmful to breastfeeding (it’s not; judicious formula supplementation in the first few days INCREASES the likelihood of extended breastfeeding)
• The lie that pacifiers cause nipple confusion (they don’t; they prevent SIDS)
• The lie that a newborn’s stomach is the size of a marble (it’s not; it’s 4X larger)

In order to support mothers, the Fed Is Best Foundation provides accurate assessments of the tiny benefits and significant risks of breastfeeding. They support breastfeeding in every way they know how, but they aren’t willing to lie to do so. How dare they?

But perhaps most egregious is the fact that the Fed Is Best Foundation supports women who can’t or choose not to breastfeed. That produces unbearable cognitive dissonance for lactivists. If it’s okay not to breastfeed (and it is okay), then the effort that they expended to breastfeed was not heroic; it wasn’t even necessary. When lactivists insist against all evidence that the Fed Is Best Foundation doesn’t support breastfeeding what they mean is that the FIBF doesn’t support their view of themselves as superior mothers. How dare they?

Sadly, cognitive dissonance and effort justification affect breastfeeding professionals nearly as much as lay people. Consider this obnoxious lie tweeted by lactivist Prof. Rafael Perez-Escamilla:

Thank you Baby-Friendly USA for exposing the FIB Foundation which is an organization based on the principles of “Astroturfing” defined [by Wikipedia]

What is Astroturfing?

Astroturfing is the practice of masking the sponsors of a message or organization (e.g., political, advertising, religious or public relations) to make it appear as though it originates from and is supported by grassroots participants… The implication behind the use of the term is that instead of a “true” or “natural” grassroots effort behind the activity in question, there is a “fake” or “artificial” appearance of support.

We have a word for that kind of tweet. The word is libel.

To date, the Fed Is Best Foundation has not chosen to pursue legal action against liars like Dr. Perez-Escamilla, but that doesn’t mean they couldn’t. Like all charitable foundations, FIBF has publicly accessible tax documents. But you don’t even have to look them up; the Foundation has published those documents on the Web. They show that there is NO secret funding source, NO corporate sponsors, nothing but real, grassroots support. Perez-Escamilla and other lactivists who lie have reason to know that they are lying, yet they do it anyway.

Why? Effort justification.

These people have devoted their entire careers to the belief that breast is best for every baby. They’ve raised and spent millions of dollars putting unethical, aggressive breastfeeding promotion efforts like the Baby Friendly Hospital Initiative into practice. Ironically — unlike FIBF founders whom they accuse of profiting from their advocacy — these liars actually DO profit from their advocacy. Their professional raison d’etre is breastfeeding and they need to believe that the effort they have expended, the money they have spent and the money they currently earn are justified by the overwhelming superiority of breastfeeding.

The cognitive dissonance that results from acknowledging that the benefits of breastfeeding are tiny and the risks significant is simply unbearable. The need for effort justification compels otherwise responsible professionals to blatantly lie in order to protect their self-image.

Prof. Perez-Escamilla and the other professional lactivists who have lied about the Fed Is Best Foundation owe them a public apology and an acknowledgement that there is no evidence of corporate sponsorship beyond lactivists’ desperate efforts to avoid confronting the facts.

Breast is NOT best for every baby and I’d be happy to debate Prof. Perez-Escamilla in print or in public on that issue. But I suspect that he, like most professional lactivists, wouldn’t dare.

The single most important thing every prospective mother needs to know about breastfeeding is this: it has serious risks as well as benefits.

Baby Friendly USA is petrified that women will find out.

Sadly for the babies who have been injured and died and their grieving families, we found out the risks of breastfeeding hard way. The scientific literature is burgeoning with papers* detailing the high rate of insufficient breastmilk especially in the early days after birth (up to 15% of first time mothers) and the brain-threatening, life-threatening consequences. We are experiencing a dramatic increase in neonatal hypernatremic dehydration, hypoglycemia and kernicterus (severe jaundice). Exclusive breastfeeding is associated with tens of thousands of newborn hospital readmissions per year at a cost of hundreds of millions of dollars.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Ethical professionals ask, “What can we do to prevent this from happening again?” Baby Friendly USA asks, “What can we do to avoid blame?”
[/pullquote]

The press is bristling with reports of lawsuits over babies who died IN HOSPITALS. They fell out of or were smothered in their mothers’ beds in the wake of closure of well baby nurseries at the behest of breastfeeding professionals. Though we’ve spent millions on major public health campaigns to alert parents to the dangers of babies sleeping in an adult bed, babies sleeping with soft bedding and babies sleeping with anyone impaired by drugs, the Baby Friendly Hospital Initiative effectively ENCOURAGES all three.

Keep in mind that the hospitalizations, brain injuries and deaths are iatrogenic. They happen BECAUSE of aggressive breastfeeding promotion.

When a baby suffers iatrogenic harm, ethical healthcare professionals ask, “What can we do to prevent this from happening again?” Baby Friendly USA asks, “How can we discredit Fed Is Best for pointing it out?”

Their answer is to attack the whistle blower who is bringing the news of deadly harms to others. In this case the whistle blower is the Fed Is Best Foundation, a non-profit formed expressly to ensure that the brain injuries suffered by a founder’s son did not happen to any other babies.

Take a look at Baby Friendly USA’s latest attempt to retaliate against them for exposing injuries and deaths. It’s a 1200 word rant claiming that the Fed Is Best Foundation is misleading people on the issue of jaundice and breastfeeding. As you read it, ask yourself:

Is Baby Friendly USA trying to avoid infant brain injuries and deaths or are they trying to avoid blame and loss of market share?

The Baby Friendly USA rant appears to have lots of points but actually makes only two:

1. How dare the Fed Is Best Foundation show that breastfeeding professionals know that breastfeeding is implicated in 90% of cases of kernicterus in the US?

Pediatrician Lawrence Gartner acknowledged this in a slide used in a lecture to breastfeeding professionals, a slide that had been uploaded to a public website.

What does BF USA propose to do about kernicterus? NOTHING of course except offer blustering nonsense:

The slides from Dr. Gartner’s lecture were posted without his permission, a gross violation of accepted professional protocol.

But you DON’T need permission. Using a small piece of an article or presentation as a vehicle for a broader discussion is “fair use.” If anyone would know about that it’s me as I sued another blogger in Federal Court for accusing me of almost the exact same thing.

2. The Fed Is Best Foundation may have used numbers that overstate the incidence of jaundice and therefore the associated brain injuries.

What does BF USA propose to do about actual cases of jaundice and associated brain injuries? NOTHING beyond quibbling about the size of the increase.

BF USA insists on maintaining the status quo. They suggest doing nothing more, changing nothing, telling member hospitals nothing as if that isn’t what led to these cases of jaundice and kernicterus in the first place.

The Fed Is Best Foundation exists precisely because this has already been an ABJECT FAILURE. The whole point is that babies are suffering iatrogenic injuries as a result of aggressive breastfeeding promotion.
But BF USA fears reform will cut into their bottom line since their source of income IS aggressive breastfeeding promotion.

The rant concludes:

We would rather not spend our time “fact checking” this organization, but we will continue to do so if that’s what is necessary to ensure mothers and families get accurate information. We consider the constant drum-beat of these falsehoods to be reckless and negligent behavior and once again call on this organization to be more responsible in providing the public accurate and scientifically-grounded data.

It would be far more accurate to have acknowledged that they’d much rather spend their time “fact checking” Fed Is Best than protecting babies from harm. BF USA is right to be afraid of the Fed Is Best Foundation. No amount of suppressing the truth or attacking Fed Is Best for exposing it avert reform; it can only delay it at the cost of further infant hospital readmission, brain injuries and deaths.

When a baby suffers iatrogenic harm, ethical healthcare professionals ask, “What can we do to prevent this from happening again?” Baby Friendly USA ask, “What can we do to avoid blame?”

It’s an incredibly ugly look!

 

*Recent publications:

• United States Preventive Services Task Force (USPSTF) guidelines
• Interventions Intended to Support Breastfeeding: Updated Assessment of Benefits and Harms
• Unintended Consequences of Current Breastfeeding Initiatives
• The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. a critical review of the literature
• Health Care Utilization in the First Month After Birth and Its Relationship to Newborn Weight Loss and Method of Feeding
• The Effect of Early Limited Formula on Breastfeeding, Readmission, and Intestinal Microbiota: A Randomized Clinical Trial

Yesterday I wrote about the ways in which midwives and lactation consultants treat childbearing women like children. Society at large is also guilty of infantilizing women. The paradigmatic example is formula advertising.

Formula advertising restrictions go back to 1981 and the Nestle debacle in Africa. Nestle and other formula companies engaged in the brutally unethical promotion of infant formula powder to women who had access to only contaminated water with which to prepare it. Tens of thousands of infants died as a result.

[perfectpullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Though adult women are trusted to determine whether or not to smoke cigarettes or consume alcohol, it is assumed they cannot be trusted to determine whether or not they wish to breastfeed.[/perfectpullquote]

The problem was the water and the solution was two fold: mandate truth in advertising about the dangers of preparing formula with contaminated water and increase Africans’ access to clean water. Instead, breastfeeding advocates seized upon this as a way to promote breastfeeding, a tactic they have continued to this day, more than 35 years after the fact.

A central pillar of lactivist efforts has been to restrict formula advertising. The World Health Organization’s Code of Marketing of Breast-milk Substitutes first published in 1981 pulls no punches about what it’s trying to accomplish. Even the title disparages the use of formula.

The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have for many years emphasized the importance of maintaining the practice of breast-feeding—and of reviving the practice where it is in decline—as a way to improve the health and nutrition of infants and young children. Efforts to promote breast-feeding and to overcome problems that might discourage it are a part of the overall nutrition and maternal and child health programmes of both organizations and are a key element of primary health care as a means of achieving health for all by the year 2000.

To that end:

Manufacturers and distributors of infant formula should ensure that each container as a clear, conspicuous, and easily readable and understandable message printed on it, or on a label which cannot readily become separated from it, in an appropriate language, which includes all the following points: (a) the words “Important Notice” or their equivalent; (b) a statement of the superiority of breast- feeding; (c) a statement that the product should be used only on the advice of a health worker as to the need for its use and the proper method of use; (d) instructions for appropriate preparation, and a warning against the health hazards of inappropriate preparation. Neither the container nor the label should have pictures of infants, nor should they have other pictures or text which may idealize the use of infant formula…

The following guidelines have also been put in place:

No advertising of such products to the public;
No use of baby pictures on packaging to idealize infant formula;
No free samples or gifts to mothers or health workers;
No promotion of such products in health facilities
No contact of mothers by company representatives.

Further refinements have involved banning marketing displays in stores and prohibiting the use of discount coupons to purchase formula as well as prohibiting the use of formula purchases in frequent shopper programs.

The advertising and marketing of infant formula is subject to greater restrictions than cigarette or alcohol advertising, both of which pose far more risk to life and health than formula. The rationale behind restrictions on cigarette and alcohol marketing is to prevent children — who are assumed to be far more impressionable and to lack the analytic powers of adults — from being tempted to use an addictive substance. The restrictions on cigarette and alcohol advertising are NOT designed to prevent adults from accessing either substance.

When it comes to formula marketing, women are assumed to be so limited in intelligence and judgment that they must be treated as children. Though adult women are trusted to determine whether or not to smoke cigarettes or consume alcohol, it is assumed they cannot be trusted to determine whether or not they wish to breastfeed. They must be pressured into it.

Since the promulgation of the WHO Code, we’ve learned a great deal about the fact that the benefits of breastfeeding are far more limited than what we originally thought. With the exception of premature infants, there is no correlation between breastfeeding rates and mortality rates. The only fully documented benefits of breastfeeding for term infants are an 8% reduction in colds and an 8% reduction in episodes of diarrheal illness across the entire population of infants in their first year. Moreover, despite the manipulative language of breastfeeding advocates, there are no “harms” of infant formula and there are real risks (hospital readmission, brain damage, death) to aggressive breastfeeding promotion.

Ironically, there are no restrictions on the marketing of “natural” and “homeopathic” remedies for infants even though they are useless at best and toxic at worst. For example, while draconian restrictions on formula marketing were being enforced, Hyland’s homeopathic teething preparations were implicated in adverse outcomes, including 10 infant deaths. Finally in 2017 the FDA recalled the products because the manufacturer had mislabeled the amounts of belladonna alkaloids they contained.

Think about that: the US government believes that mothers are adults capable of judging dangers of alternative infant remedies, some of which are toxic, but so incapable of judging the “dangers” of formula that they must be protected from formula marketing as if they were children.

Women are either capable of making safety decisions or they are not. If they are capable of determining whether or not to consume cigarettes or alcohol then they are capable of determining whether or not to breastfeed or use formula. There should be no special restrictions on formula advertising or marketing. To allow them, or worse to promote them, is to demean women.

We treat children differently than we treat adults.

• We presume we know better than they what they need.
• We believe we have an obligation to guide them on the right path.
• We know we understand risks better than they do.
• To the extent they disagree, we ascribe it to immaturity and lack of knowledge.
• We are sure that if they “understood” what was at stake, they would want what we want.
• We accuse them of being inordinately swayed by outside pressures.
• We feel obliged to force them to do things they don’t want to do “for their own good.”

All these reactions are perfectly appropriate if we are talking about a seven year old. They may even be appropriate if we are talking about a seventeen year old, although they may not. Surely, though, they are an inappropriate as a way to treat adult women.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is unacceptable to treat women like children even for “their own good.”[/pullquote]

Which begs the question:

Why do midwives and lactation consultants treat women like children?

Consider how midwives treat women who wish to have maternal request C-sections instead of vaginal births:

Most midwives assume that vaginal birth is better than C-section except in rare circumstances.

They imagine they have an obligation to guide women (“support them”) toward vaginal birth.

They believe they understand the risks better than women do even though they habitually ignore many of the risks that are most relevant to women like future incontinence and sexual dysfunction.

To the extent that women disagree, they ascribe this to lack of knowledge about the “real” (often rare, sometimes merely theoretical) risks.

They are sure (and they constantly reassure each other on social media) that women want what they wish to give even if the women themselves appear not to realize it.

To the extent that women disagree, they imagine that they are “socialized” to fear the pain of birth or swayed by obstetricians playing the “dead” baby card.

That’s how they justify their pressuring women to avoid C-sections, avoid interventions, and justify actively seeking to limit women’s access to epidurals.

But that’s nothing compared to lactation consultants:

Lactation consultants have codified treating women like children into the oxymoron of the Baby Friendly Hospital Initiative. It’s an oxymoron because it isn’t friendly to babies. It actually harms them by increasing hospital readmissions for dehydration and jaundice and by increasing infant deaths within the hospital from falls from or being smothered in maternal beds.

The baseline assumption of the BFHI is that women can’t be trusted to know what’s best for themselves and their babies. They must be subjected to a rigidly curated propaganda offensive.

Lactation consultants are sure (despite scientific evidence to the contrary) that breast is best for every mother and baby. They are so sure that they have enshrined their belief in the phrase “breast is best” and plastered it to the walls of midwives’ offices and hospital corridors. They endlessly harangue women about the “benefits” of breastfeeding, most of which have proven illusory.

Lactation consultants believe they understand the risks of formula feeding better than mothers do, but most of those presumed risks are based on poorly done epidemiological research riddled with confounders and have not occurred in real world experience.

To the extent that women wish to use formula, lactation consultants ascribe their desire to ignorance, lack of “support” and marketing by formula companies (despite the fact that they have banned marketing by formula companies).

Lactation consultants seek to restrain women who wish to use formula by placing stumbling blocks in their way: locking up formula in hospitals, forcing them to sign formula consent forms, limiting what health professionals are allowed to tell them on the topic.

Lactation consultants have gone so far as to fabricate risks that don’t even exist such as the “risk” of nipple confusion from a bottle and the “risk” of formula supplementation even though research shows that formula supplementation prevents hospital readmission and leads to increased rates of extended breastfeeding.

Lactation consultants are sure that their tactics are justified by an obligation to force women to breastfeed for “their own good” and their babies’ health.

But women are not children and it is completely inappropriate to imagine that they are. Women are adults capable of determining what is best for themselves and their children.

It follows therefore:

Women should not be pressured into avoiding interventions and epidurals or pressured into having a vaginal birth

Women who don’t find empowerment through their reproductive functions don’t need to be educated or “supported” into making choices that are different than the ones they articulate.

The arbiter of clinical practice MUST be scientific evidence, not intuition and certainly not providers seeking validation of their own choices by patients mirroring them back.

This applies equally to breastfeeding. As between breastfeeding and formula feeding there is no “best” way to feed a baby.

Midwives and lactation consultants need to hold themselves to a higher standard than what they currently embrace. It is completely unacceptable to treat women like children even “for their own good.”

Most breastfeeding scientists and much of the public often consider epidemiologic associations of breastfeeding to represent causal effects that can inform public health policy and guidelines. However, the emerging picture of breastfeeding research is difficult to reconcile with good scientific principles. The field needs radical reform.

If that paragraph seems familiar to readers of scientific journals it is because it is a paraphrase of the lead paragraph of John Ioannidis’ new paper The Challenge of Reforming Nutritional Epidemiological Research.

Most nutrition epidemiological research is nonsense and breastfeeding epidemiological research is a subset of nutrition research.

Ioannidis writes:
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We should ignore hasty statements of causal inference and advocacy to public policy made by breastfeeding researchers.[/pullquote]

In recent updated meta-analyses of prospective cohort studies, almost all foods revealed statistically significant associations with mortality risk…

Assuming the meta-analyzed evidence from cohort studies represents life span–long causal associations, for a baseline life expectancy of 80 years, eating 12 hazelnuts daily (1 oz) would prolong life by 12 years (ie, 1 year per hazelnut), drinking 3 cups of coffee daily would achieve a similar gain of 12 extra years, and eating a single mandarin orange daily (80 g) would add 5 years of life. Conversely, consuming 1 egg daily would reduce life expectancy by 6 years, and eating 2 slices of bacon (30 g) daily would shorten life by a decade, an effect worse than smoking. Could these results possibly be true? Authors often use causal language when reporting the findings from these studies (eg, “optimal consumption of risk-decreasing foods results in a 56% reduction of all-cause mortality”). Burden-of-disease studies and guidelines endorse these estimates. Even when authors add caveats, results are still often presented by the media as causal.

Breastfeeding studies are exactly the same. The breastfeeding equivalent of claiming 12 hazelnuts a day would prolong life by 12 years is claiming that breastfeeding could save 800,000 lives per year. That’s equally nonsensical. It’s based on a mathematical model that has never been validated. Even when formula companies engaged in their unethical campaign to promote formula in Africa, the actual death toll at the peak year of formula promotion was 65,000. That represents 65,000 preventable tragedies, but nowhere near what we might expect if breastfeeding researchers’ claims were true.

Since then according to Paul Gertler whose research established the 65,000 peak death toll:

…[T]he annual death toll has dropped to about 25,000, driven by improved access to clean water in the Southern Hemisphere.

That’s just 3% of the number claimed by breastfeeding researchers.

How do good people end up making such bad claims?

These implausible estimates of benefits or risks associated with diet probably reflect almost exclusively the magnitude of the cumulative biases in this type of research, with extensive residual confounding and selective reporting. Almost all nutritional variables are correlated with one another; thus, if one variable is causally related to health outcomes, many other variables will also yield significant associations in large enough data sets. With more research involving big data, almost all nutritional variables will be associated with almost all outcomes. Moreover, given the complicated associations of eating behaviors and patterns with many time-varying social and behavioral factors that also affect health, no currently available cohort includes sufficient information to address confounding in nutritional associations.

Moreover:

…[T]he literature is shaped by investigators who report nonprespecified results that are possible to analyze in very different ways. Consequently, meta-analyses become weighted averages of expert opinions.

That’s precisely what has happened with breastfeeding research. Researchers continue to make absurd claims about the benefits of breastfeeding based on extrapolations from small studies with multiple confounding variable; this despite the fact that they can find NO EVIDENCE in real life that their claims are true. There is no evidence that breastfeeding rates are correlated in any way with infant mortality and there’s no evidence that increasing breastfeeding rates leads to corresponding declines in infant deaths.

Okay, so perhaps nutrition and breastfeeding researchers have exaggerated various risks and benefits, but what’s the harm?

Nutritional research may have adversely affected the public perception of science. Resources for some of these studies could have been better spent on unambiguous, directly manageable threats to health such as smoking, lack of exercise, air pollution, or climate change. Moreover, the perpetuated nutritional epidemiologic model probably also harms public health nutrition. Unfounded beliefs that justify eating more food, provided “quality food” is consumed, confuse the public and detract from the agenda of preventing and treating obesity.

The harm is even larger in breastfeeding research because breastfeeding has risks as well as benefits. Aggressive efforts to increase breastfeeding rates have led to tens of thousands of neonatal hospital readmissions for dehydration and jaundice, some of which have culminated in infant brain injuries and deaths.

To the extent that nutritional epidemiological research has revealed anything at all, it has demonstrated that there is no such thing as a nutrition “silver bullet.” There is no food, herb or supplement or combination of food, herbs and supplements that magically assures health. That goes for breastfeeding, too. Despite what breastfeeding researchers claim, breastfeeding is NOT a silver bullet for infant health and in many circumstances formula feeding may actually be healthier.

Ioannidis concludes:

Reform has long been due. Data from existing cohorts should become available for reanalysis by independent investigators. Their results should be presented in their totality for all nutritional factors measured, with standardized methods and standardized exploration of the sensitivity of conclusions to model and analysis choices. Readers and guideline developers may ignore hasty statements of causal inference and advocacy to public policy made by past nutritional epidemiology articles. Such statements should be avoided in the future.

The same goes for breastfeeding. Readers and guideline developers should IGNORE hasty statements of causal inference and advocacy to public policy made by past breastfeeding epidemiology articles. And breastfeeding researchers should avoide such claims in the future. They are not true and they may even be harmful.